| In the Bryonia pneumonias there is usually a history of a fairly gradual onset. The kind of story you get is that the patient had been out of sorts for a day or two, complaining of indefinite feelings of malaise, and then that one morning he woke feeling thoroughly ill, very often with an attack of sneezing and a feeling of blocking in the head. During the morning he felt shivery, he may have had an actual rigor, and by the afternoon he had a good going temperature. The probability is that these people have been running a slight temperature for the previous twelve to twenty-four hours, though they have not consulted you for it; they have certainly been off colour.|
When you see a Bryonia pneumonia the impression you get is of definitely congested heavy-looking, sleepy patient.
The face is somewhat dusky in colour. The patient feels hot, and usually has a hot, damp sweat. It is not a profuse perspiration but the skin is hot and damp. Twelve to twenty-four hours later you very often get a dusky appearance of the extremities. About the same time you find the lips are beginning to turn dusky in colour, and they have very soon tend to become dry and to crack. They have a somewhat swollen appearance.
The patient very often complains of a rather intense frontal headache which settles down over the eyes. Often it is much more a feeling of weight than of actual pain, but it becomes painful on any movement or exertion, such as talking or sitting up. Another thing you can link on to this aggravation of the headache from sitting up is that these Bryonia patients very often feel generally extremely ill on sitting up, they become giddy and somewhat faint.
In these Bryonia pneumonias you always find a heavy, thick, white coating on a dry tongue; the mouth feels dry, and the patient is very thirsty. Very often there is a bitter taste in the mouth, and the main desire is for large quantities of cold water. In this connection there is one point that is worth remembering about the nursing of these patients, and that is that if you let them drink as much cold water as they want it is bad for them and very often makes them feel sick. So when dealing with a Bryonia patient it is wise to regulate the quantity of water they take, especially at any one time, and not to allow them to have all they would like.
The next thing to consider is the mental reaction of Bryonia patients. Bryonia patients, as I said before, look heavy and dull, and they very definitely dislike being disturbed at all. They resent having to do anything, for instance, having to move, or having to turn over to be examined. They dislike having to talk, and talking upsets them and makes them worse. They are very short tempered and they are difficult to satisfy. They often ask for something and refuse it when it is brought to them, they are thoroughly cross-gained. They easily become annoyed, and if they are annoyed it always aggravates their physical condition.
I have often seen a Bryonia pneumonia who was doing quite well until he had visitors in who annoyed him and promptly he had a rise of a degree or a degree and a half of temperature in a couple of hours, with increase of physical distress, increase of cough, and very often marked increase of pain. So, again from the nursing point of view, you are very wise to prohibit visitors to your Bryonia patients. This is sometimes a little difficult to do, because the Bryonia patients rather tend to harp on their business affairs, they think about them, they talk about them, they often worry about them, and very often they ask to be allowed to see somebody from the office. If you do allow it, they are most likely to be annoyed at what the people in the office are doing, and this annoyance is very bad for them. So, from the practical point of view, never allow any possibility of such a thing happening in the case of a Bryonia patient.
AS far as the actual physical condition is concerned, in Bryonia you are much more likely to find the right lung involved than the left. If the disease is more extensive, you find the right lung involved to a greater degree than the left. But do not rule out Bryonia altogether because you have a left-sided pneumonia; I have seen several pneumonias now which were confined to the left side but in which Bryonia was indicated and worked very well indeed. So do not say, ” well, this is a left-sided pneumonia, it cannot be a Bryonia”-it can. Much more commonly you find the right side involved, but the fact that it is left sided does not rule Bryonia out.
In these Bryonia cases you are very liable to get a pleuro- pneumonia, rather than a straight pneumonia, with very sharp, intense, pleuritic pain. And there are one or two points about that pain which are sometimes helpful. First of all, it is very much aggravated by any movement on the patient’s part. Secondly, it is usually mainly on the right side. Thirdly, the patient likes to lie on the side that is affected; if it is a right-sided pneumonia you find him turning over on to the right side as that is the most easy position, and if it is a left sided pneumonia you find him turning over on to the left side.
When the patient coughs-which he does a great deal-he has intense pain in the chest, and it is then that you see the Bryonia picture of the patient sitting up in bed trying to hold the chest with his hands to keep it quiet while he is coughing. And, again from the clinical point of view, you do give your Bryonia patients great help by strapping up the affected side of the chest; either adhesive plaster or a tight binder gives great relief. You know the modern custom is to put antiphlogistine on the pneumonia patient; well, it does help the Bryonia case, but it is the splinting of the chest that helps, more than the antiphlogistine itself.
The breathing of the Bryonia patient is always very short. He takes short, panting breaths, keeping the breathing as shallow as possible because any movement of the chest wall hurts. So you see the patient sitting firmly propped up, breathing short, panting breaths.
Usually in these Bryonia pneumonias there is a certain amount of irritation in the throat, and the patients mostly have a rather hoarse voice.
There are one or two other points if the pneumonias has gone on a little further and run into fourth, fifth, or sixth day. These patients then become more toxic, more drugged looking, rather heavier, and they are liable to develop a low type of muttering, wandering delirium; it is never a very violent one. IN their delirium they are very often uncertain as to where they are, for instance, if they are at home they do not recognize it and they say want to go home. They are also very apt to develop that old Bryonia symptom of worrying about their business; they think they are still at work, they have a deuce a lot to do, and they keep on talking about it and imagining they are still back at the office.
Then occasionally-but not so commonly-you find one of these Bryonia patients becoming acutely anxious, and when this anxiety state develops you will quite often get him becoming restless. That is a little apt to confuse you because you have it firmly imprinted in your mind that Bryonia is very much aggravated by any movement. But if you go into the question he will tell you that, although any movement increases his discomfort and his pain, he just cannot lie still even though moving hurts him. It is never the extreme restlessness that you get in some of the other drugs, and if it is associated with that nervous anxiety do not rule out Bryonia on the fact that the patient is restless.
Another Bryonia distinguishing point is that the patients are hot blooded. They feel hot, and they are uncomfortable in a hot atmosphere., If the room is to warm it will aggravate their cough, and they very much prefer a cold room and a current of air.
Well, that it is the commonest type of pneumonia, at least in this country. Possibly, as I say, it is rather commoner in the spring than in the real cold, wintry weather, and you will find that Bryonia will cover the majority of the cases you see of that type.
| The next commonest drug in pneumonia is Phosphorus.|
As a rule the phosphorus pneumonia develops rather move quickly than the Bryonia one. The kind of story I have come to associate with a Phosphorus pneumonia is that the patient had been feeling very tired for possibly twelve or twenty-four hours, and then he probably went out into a cold atmosphere and on going out felt an acute sense of oppression or tightness in the chest. Usually the same night he felt hot and developed a dry cough. Possibly there was also a little hoarseness, or even actual loss of voice, and the feeling of tightness and oppression in the chest very much increased. Next he developed a sort of catchy respiration, a slight embarrassment on inspirations. and the breathing became rather difficult.
In appearance you will find the Phosphorus pneumonias have a brighter red flush than the Bryonias-they are not quite so dusky. Although they have a flush, when they are peaceful it tends to die down a bit, and you do not get the same degree of cyanosis of the lips. The skin surface is hot, and it is moist, but not so moist as in Bryonia. Though the patients are obviously tired they do not give you the same impression of sleepiness as the Bryonias do; they are more awake, they are more worried, and they are more anxious.
On seeing these patients you are immediately impressed by the fact that their respiration is seriously embarrassed. Their breathing is obviously difficult, and they say they cannot get enough air. Very early in the disease there are signs of the accessory respiratory mechanism coming into play, the chest wall is heaving a bit, the nose is flapping, and the patient is obviously having difficulty. In these earlier stages the difficulty is out of proportion to the actual physical signs to be found in the chest. Next you notice that the patient tends to be rather tremulous. The hands are a little shaky, the facial muscles are twitching, and there may also be irregular twitching of the alae nasi.
Always in these Phosphorus pneumonias there is a very trying, tormenting, irritating cough. And that cough is very often accompanied by a feeling of rawness, or burning in the chest.
In the earlier stages, I think, the Phosphorus tongue tends to be dry and reddish, and gives you the appearance of being a little swollen. But by the third or fourth day there is a certain amount of light, dry, white or whitish-yellow coating. These Phosphorus patients are always intensely thirsty, and their desire in pneumonia, as always, is for cold drinks. Phosphorus patients, no matter what their ailment, always want cold drinks, but in pneumonia, with their very dry mouth, they very often ask for something juicy or sour rather than plain cold water.
There is another point that sometimes helps you in the diagnosis of your Phosphorus pneumonias, and that is the position which patients find most comfortable. They want to be propped up, which is not surprising when you consider the feeling of oppression in the chest, but in addition to that you often see them with the chin tilted up and the head thrown well back, which they say very considerably helps their difficult breathing. That is a useful point, because it distinguishes Phosphorus from some of the other drugs which take up a position leaning forward with the elbows on the knees. There are not many drugs which adopt the Phosphorus attitude, and it always very suggestive when you see it.
Another point which ought to help you is that they are chilly patients; they feel the cold, and any draught of cold air is liable to excite an attack of coughing.
A further helpful point is that in their pneumonias, with their state of anxiety and distress, phosphorus patient very much dislike being left alone. They become scared if they are alone, and they feel very much more peaceful and comforted if they have someone about, particularly if they are in actual contact with them. It is not enough merely to sit by the bed of a Phosphorus patient, he wants you to hold his hand, and the actual physical contact gives him sense of great relief. There is one point I missed in both these drugs, and that is the character of the sputum. In the Phosphorus patient in the earlier stages there is a very tormenting, dry cough, with very little sputum indeed. By about the third day that sputum tends to increase,and there is a rather bright red streak through the mucous sputum. By the fourth day that red streak is becoming darker, and very soon afterwards the typical rusty sputum appears. In the Bryonia case the sputum is much darker in colour right from the beginning; even before it reaches the actual rusty stage of consolidation the blood in the sputum is darker than that of Phosphorus. And the sputum in Bryonia is, I think, more sticky, more difficult to expel, and rather tends to hang about the mouth. The phosphorus sputum is liable to be a little more watery, and although scanty it is easier to get up.
As regards the temperature and the pulse rate in Bryonia and Phosphorus there is awfully little to distinguish them. I think possibly the temperature tends to be a little higher in Phosphorus than it does in Bryonia, and possibly the pulse is a little fuller, but they both run a temperature round about 103 degree, and they both tend to have quite a full, strong pulse.
| The third of these frank pneumonia drugs is Veratrum viride, and here you have a very clear-cut picture indeed.|
The onset is very similar to that in a Phosphorus case. It develops at much the same rate, but is not attended by the same degree of oppression of the chest. In Veratrum viride there is a very much more rapid rise of temperature, and there is apt to be a much higher fever, probably running up to 105 degree. There is a difference in the colour of the Veratrum viride patient and the Phosphorus patient. It is a little difficult to put into words, though if you could only see the two patients it would be quite easy to point out the difference. Although both are congested, and both have red faces, yet I think the Veratrum viride patient gives you the impression of being a little more livid than the Phosphorus one; I think that is the nearest one can get to it.
The Veratrum viride patient always complains of a feeling of intense pulsation, he feels as if his heart were simply pounding out through the chest wall. The pulse is full and bounding and with that you very often get the impression that the Veratrum viride patient’s face is rather bloated and swollen looking.
There is always marked excitement in these pneumonias. Very violent delirium may develop quite early, and the patients are liable to have all sorts of obsessions that they see faces and figures on the wall. It is always something terrifying that they see, and with that state of intense excitement, in Veratrum viride you will always find widely dilated pupils.
You will realize that this is almost word for word a repetition of the description of the picture you meet with in Belladonna, but it is impossible to confound the two. Belladonna has an intense flush and a burning dry skin; whereas Veratrum viride is livid and covered with beads of sweat.
In spite of the high temperature, and without any fall in temperature, there is always profuse perspiration in the Veratrum viride patients. I have seen them in pneumonia with a temperature of 105 degree, the sweat standing out in beads all over, and in spite of that profuse sweat there was no drop in temperature at all.
These Veratrum viride patients are always intensely thirsty, and very often with their thirst there is a feeling of slight nausea. There is one point, a clinical one, that I want to give you about their thirst. I have never come across it in any of the Materia Medicas, but clinically I have had it verified quite frequently, and that it is that the Veratrum viride patients often complain of every thing they takes tasting abominably sweet. For instance, I remember the first child I saw with a Veratrum viride pneumonia and one of his bitterest complaints was that everything he took, plain water, fruit drinks, anything in fact, tasted abominably sweet. We had an awful hunt to try and match it up with a drug, and finally it was on his general indications, not on his sweet taste, that he got his Veratrum viride, and he promptly cleared up. Since that time I have had the symptom verified at least half a dozen times. You do not always get it, but when you do it is a useful lead towards the possibility of Veratrum viride.
There is another point which is almost diagnostic of Veratrum viride when you meet it, and it concerns the tongue. You get two types of tongue in Veratrum viride. One has a thick, yellowish coating, and it is not uncommon. But the one that you look for, and hope for, is a tongue with a thick coating and a bright red streak down the centre. If you have a pneumonia with a high temperature, full bounding pulse, generalized sweat, thirst, and that red streak down the centre of the tongue, you need not bother your head any further; that is Veratrum viride, and will clear up on it every time. I remember one year we had six Veratrum viride pneumonias in the hospital during the winter; they all had Veratrum viride, and every one of them had their crisis the same night. So if you have these legs to stand on you are perfectly safe to push in Veratrum viride, and you will get your results every time.
There is one other point that I have had verified. You know the Bryonia patients have an aggravation from having to sit up, it makes them giddy and they very often resent having to move.
In Veratrum viride, also, there is an aggravation from sitting up, but it is different; the patients do not become giddy, but they complain that their vision becomes dim. I have verified that clinically on several occasions. You can tack on to that another Veratrum viride symptom-one which is not uncommon, I think, in the drugs with widely dilated pupils-and that is that you always find a certain amount of photophobia in the Veratrum viride patients.
The sputum in Veratrum viride comes in about midway between the Phosphorus and the Bryonia ones; it is not quite so bright as the Phosphorus and not quite so dusky as the Bryonia. It is a little difficult to expel, it is a little sticky, and there is always a certain amount of chest pain while coughing and trying to bring it up, but there is not the acute, stabbing pain of Bryonia, or the raw burning of Phosphorus.
| I think most of the pneumonias in which you give Bryonia without success are cases in which you have missed Chelidonium. The two are very alike in appearance, and they are very alike in the character of their pains. They are also very similar in onset. The Chelidonium patients are usually rather out of sorts, and you very commonly find that they have had a loss of appetite and general discomfort preceding the onset of their pneumonias.|
In Chelidonium the appearance is somewhat dusky. It is rather similar to the Bryonia duskiness, but, instead of the bluish look that you find in Bryonia, there is a slightly yellowish tinge in Chelidonium. On this yellowish base there is liable to be a rather localized, deeper, malar flush, and quite often that flush is one sided. Very commonly it is right side which is more flushed than the left.
As far as mentality is concerned, these two drugs are very similar, or at least they appear to be so at first sight. The Chelidonium patients are lethargic, they do not want to be disturbed, they do not want to make any effort, they are as much aggravated by movement as the Bryonia patients, and they are definitely irritable. But their irritability, when you get down to it, is rather different. Bryonia patients are absorbed in their own worries, and say “for heaven’s sake leave me alone”, whereas Chelidonium patients are much more spiteful and snappy. For instance, you may be cross-questioning them and going along quite nicely, and suddenly they spit out at you in the most surprising and uncivil way-that is the typical Chelidonium reaction.
Then always in Chelidonium-at least in every Chelidonium case I have seen-the involvement is on the right side. Bryonia also has the involvement on the right side, and yet it is just here that you get distinguishing points. In the Bryonia case as a rule the pains in the chest are much more round towards the axilla, or round towards the back. In Chelidonium the pains tend to be more towards the front, and go right through to the scapular region. Instead of the sharp, stabbing pains being in the side, you get them more in the front of the chest and going right through to the back.
As regards the appearance of the tongue in the two drugs, the Bryonia one tends to be whitish, and the chelidonium one tends to be yellow. As far as the sputum is concerned, I think there is more profuse expectoration in Chelidonium, it is not so difficult to get up, and it is not quite so dusky as the Bryonia sputum. Then you get your outstanding distinction. In Bryonia you have an intense thirst for cold drinks. In Chelidonium you have a desire for hot things. So there the two drugs at once part company. As a rule the position taken up by the two patients is different. The Bryonia patient tends to turn over on to the affected side. The Chelidonium patient likes to sit up learn forward. Both keep as still as they possibly can.
By the way, there is one point I have missed in all the drugs, and that is their period of aggravation. In Bryonia it tends to be round about 9 o’clock in the evening. Chelidonium has two periods of aggravation, it has one about 4 o’clock in the afternoon, and another about 4 o’clock in the morning, so there is a double periodicity in the twenty-four hours. As far as Phosphorus and Veratrum viride are concerned, there is no definite hour of maximum intensity, but both tend to become worse in the evening just before nightfall, when there is a period of increased excitement, increased nervousness, and increased apprehension.
Well, these are the main drugs for your ordinary, frankly developed pneumonias.
Dosage in Developed Pneumonias.
Where you are dealing with any of these typical lobar pneumonias I think the question of dosage is really quite simple.
There was a good deal of difference of opinion, and I think there is possibly some difference still, as to the optimum potency in these frank pneumonias, but having watched it here over the last twenty years I have no doubt myself as to what gives the best results.
When I came here first almost everyone in the hospital was using low potencies in these cases. Later some of the men started using medium potencies-usually a 30, and with great courage a 200. In America I had been taught to use much higher potencies, and of later years this practice has been more and more adopted here. Now we are using all potencies up to the very highest, and I am convinced that, where the prescribing is accurate, the best results are obtained by the use of the very highest potencies. I should say that in my own practice, in the average case, I would prescribe a 10 m, though where the indications were very clear my preference would always be to go higher provided there were no contra-indications. I give cm’s in preference to 10 m’s if I am perfectly certain that I have the right drug.
Then as regards repetition. Watching the results again, the average case of pneumonia, when it is frankly developed, will require at least six doses of the medicine; it may require more. One finds that the average length of action of each dose is round about two hours. That is to say, one gives a dose, and in two hours time one will find the patient needs a repetition. So in practice what one does is to order six doses of whatever potency one chooses, in the average case probably a 10m, and have it repeated every two hours.
In the great majority of cases you find that is all the medicine that is required; in the frank, straight case, one prescription will be sufficient, you will get a crisis, and you will not have to repeat. In a minority of the cases you will find that you have to keep up your administration after the twelve hours, but if you do I think you will find that you do not have to repeat so frequently, you will probably have to give another three doses in all, at four-hourly intervals.
Frank Developed Pneumonia